Commentary: Poverty and mental health

Poverty tends to play a major role in the genesis of certain psychiatric disorders. This relationship is of interest to both researchers and clinicians. However, there are challenges in defining poverty (which are often ignored), developing explanatory models used to understand the relationship between poverty and mental illness, and determining whether the relationship is direct or indirect. Additionally, when people who are living in poverty seek medical help, especially in countries where the healthcare system is primarily private, specific issues of access and acceptance can arise.

Recently, the relationship between poverty and mental illness has been identified as a major public health, human rights and developmental priority for the global community (Lund et al., 2011; Patel et al., 2018). Studies on the social determinants of mental health (SDoMH) have confirmed the negative effects of poverty on mental health, wellbeing and physical health at the population level (Herrman et al., 2022; Marmot, 2010), However, still more work is needed to understand the impact of poverty on mental health care at the individual clinician-patient level.

The study by Ballo and Tribe (2023) (in this issue) highlights some of the major challenges in working in clinical settings with people affected by poverty and mental illness. Although the number of participants is small, and the majority are white (which may conflate the observations), this is an unusual and important study. The authors zoom-in from the population level to look at the experiences of individuals in the consulting room. Their findings rightly draw our attention to tensions and ethical dilemmas in the therapeutic space in such settings. Clinicians alone cannot manage the impacts of the SDoMH amongst their individual patients, but may also feel conflicted in limiting themselves to merely treating the signs and symptoms of illness.

The impact of the SDoMH is not new. In many parts of the world, clinicians are aware of the impact of issues like poverty at the population level, but do not frequently explore their potential impact amongst their individual patients (Moscrop et al., 2020). Over seven decades ago, Milner (1952) applied the metaphor of an artist’s frame to describe the process of distinguishing between the content in the consulting room and what happens out of session. The limits of the therapeutic frame are influenced by changing societal expectations of mental health services, as well as individual therapists’ perceptions of their scope of practice. For instance, socioeconomic status has been an increasing focus in clinical practice in America (possibly to inform approaches to cost containment) and Canada (possibly due to concerns about health care equity), but not in other parts of the world, such as the United Kingdom (Moscrop et al., 2020).

Contemporary therapeutic frames can involve mental health clinicians having dual roles as both clinicians and social justice advocates (Mallinckrodt et al., 2014). As Ballo and Tribe’s (2023) findings in this issue highlight, this can lead to clinicians taking issues faced by patients ‘into their own hands’, and the therapeutic frame expanding beyond clinical issues, alone. The perceived roles of participants in the Ballo and Tribe (2023) study resemble the model of therapists as case managers, which may not always be possible. The case management model rose to prominence following the closure of psychiatric institutions that previously housed the socioeconomically disadvantaged and the mentally-ill (who were very often the same people) (Mueser et al., 1998). In contemporary practice, as highlighted by the Ballo and Tribe (2023) study, the case manager clinician must neccessarily work at the interface of both the psychological and the social. An psychological exclusively frame risks interpreting reluctance to discuss money as resistance to recovery, while an exclusively social frame risks challenging professional boundaries and giving rise to the rescue fantasy.

Ballo and Tribe (2023) describe feelings evoked in working with people affected by poverty and mental illness – hopelessness, frustration, distress, and dissatisfaction – and how these can resemble the feelings of the patients themselves. The notions of transference and counter-transference thus become incredibly important. These may be further complicated by contrasts in power status in therapy, especially if therapist and patient come from markedly different social strata. The theme of deprivation runs throughout the patient’s experience of the world, and as a parallel process in the services seeking to support them. Therapists may well require more practical support, training, and awareness about the links between symptoms and circumstance but they may also need to work with other stakeholders as advocates for their patients. There is particular value in individuals learning to reflect on their work as being one part of a network of people and services all responding to SDoMH.

Tribe and Ballo’s (2023) findings about burn-out and self-care further emphasises the importance of clinicians understanding themselves as being part of a broader system with collective responsibility to integrate care around psychological and social factors. Participants in this study appeared to already be in favour of adopting roles of clinician-advocates, and may have likely represented conscientious individuals who are perhaps more likely to experience burnout than others (Alarcon et al., 2009). Their experiences highlight the imperative for services to adopt models where advocacy is a standard part of the service delivery, and not just an add-on managed by the particularly socially conscious.

This work by Ballo and Tribe (2023) makes a valuable contribution to increasing awareness and emphasising the ‘social’ in the ‘biopsychosocial’ model of care (Engel, 1977). It is essential to incorporate some of these observations into training for all health professionals to help them become aware of the SDoMH and their impact both at the population level and within the consulting room. Training institutions have a major role to play in making enquiries into socioeconomic status a standard part of clinical practice, as well as fostering regular reflection on how issues like poverty influence the nature of the work, pathways into care and therapeutic engagement. In addition, of course poverty often forms just one factor in a syndemic. There may be a great diversity of clinician responses to the challenges associated with this work when mediators like gender, race and religion are also potentially shaping the transference, as shown by Ballo and Tribe (2023).